Current Distribution and Trends in the Location Pattern of Pediatricians, Family Physicians, and General Practitioners Between 1976 and 1979

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Current

Distribution

and

Trends

in the

Location

Pattern

of Pediatricians,

Family

Physicians,

and

General

Practitioners

Between

1976

and

1979

Peter P.

Budetti,

MD, JD,

Phillip R. Kletke, PhD, and John P. Connelly, MD

From the Institute for Health Policy Studies and the Department of Pediatrics of the University of California, San Francisco, and Department of Health Systems, Research and Development of the American Academy of Pediatrics, Evanston, Illinois

ABSTRACT. The literature suggests that pediatricians in the United States are concentrated in the more densely

populated regions and states, whereas family physicians and general practitioners are more likely to settle in rural areas. The rapidly increasing supply of all child health physicians had led many to hypothesize that the tradi-tional geographic preferences of pediatricians would ex-pand to include smaller communities. Data for 1976 to 1979 confirm the urban concentration of pediatricians and the more even distribution of family physicians and general practitioners. These data also demonstrate a marked imbalance of pediatricians within county groups, resulting in some areas of shortage even within highly metropolitan communities. Evidence of a trend toward increased dispersion of pediatricians into urban shortage areas is presented, but there is no indication that enough pediatricians will settle in rural areas to meet the needs of children in those small communities. Pediatrics 70: 780-789, 1982; pediatric manpower, child health

physi-cians, family physicians, general practitioners, supply

and distribution.

In recent years, a number of studies have pointed out an imbalance in the geographic distribution of pediatricians in the United States compared with the distribution of children.’ At the same time, it has been argued that family physicians are settling in areas left unserved by pediatricians and that these practitioners should be seen as the only likely source of child health care in those communities. Now, an additional issue has arisen as it has become

Received for publication Dec 7, 1981; accepted April 16, 1982.

Reprint requests to (J.P.C.) American Academy of Pediatrics, Department of Health Systems, Research and Development, 1801 Hinman Aye, P0 Box 1034, Evanston, IL 60204.

increasingly clear that the number of pediatricians and all child health physicians is growing rapidly and disproportionately to the child population in the United States.7 The new debate centers around assertions that, as the supply of physicians in-creases, specialists such as pediatricians will mi-grate to small areas.8 Such migration would obviate the need for family physicians to settle in those areas. In this paper, we analyze recent data on the distribution and trends in the choice of practice location for pediatricians, family physicians, and general practitioners.

Previous studies have consistently noted the con-centration of pediatricians in urban areas. In a 1975 survey limited to fellows of the American Academy of Pediatrics (AAP), Burnett and Bell’ reported that only 8.9% of those responding were practicing in rural areas, whereas 57.4% were in urban areas, and 33.6% were in the suburbs. They estimated that there were only 2,575 children less than 18 years of age per pediatrician, on average, in urban and sub-urban communities, but that there were 6,347 chil-dren for each pediatrician in rural areas.

The Graduate Medical Education National Ad-visory Committee (GMENAC) stated that 64.1% of all counties in the United States had no pediatrician as of 1975.2 The concentration of pediatricians in a few areas was particularly noteworthy-less than 10% of all counties exceeded the national average of 9.5 pediatricians per 100,000 general population (including both children and adults).

Lawlor and Reid3 analyzed data from the 1975 Physician Masterfile of the American Medical As-sociation to study the effect that the supply of physicians in one specialty has on the presence of

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hierarchi-cal pattern in the location of physician specialists by county. That is, in many counties more special-ized physicians were found only when less special-ized physicians were present. Pediatricians and gen-eral practitioners were found to be at opposite ends of the scale for primary specialists. Therefore, as

county population size and density increased, gen-eral practitioners appeared first, followed by general surgeons, general internists, surgical specialists, ob-stetricians and gynecologists, and pediatricians. The population of counties with general practition-ers only averaged 10,927, whereas those counties with pediatricians and all other primary specialists averaged 51,382 inhabitants.

In 1976, Wright4 studied the distribution of Board-certified pediatricians. The respondents to that questionnaire demonstrated state-wide ratios ranging from 0.56 respondents per 10,000 children less than 18 years of age in South Dakota to 5.0 per 10,000 children in the District of Columbia. Pedia-tricians were concentrated in states along both coasts and around the Great Lakes, with the lowest ratios occurring in Mountain, Great Plains, and Mississippi Valley states. Overall, more than 60% of pediatricians were in communities with a popula-tion of 100,000 or more, whereas less than 14% were in rural or small suburban communities.

Thompson et al5 have compiled and published data for the American Academy of Pediatrics on the supply and distribution of pediatricians by states. Their figures for 1977 demonstrated a pat-tern similar to that found by Wright. Based on the

AMA Masterfile, a more complete sample than Wright’s, their ratios ranged from 10 per 100,000

population less than 18 years of age in South Da-kota to 98 per 100,000 population in the District of Columbia. They also showed that in the vast ma-jority of states, there were fewer than 2,500 children per child health caretaker.

Budetti et al6 recently analyzed data from the University of Southern California’s Manpower Studies conducted in 1977 and demonstrated that family physicians were distributed into metropoli-tan and nonmetropolitan areas in a manner similar to the distribution of the general population, whereas pediatricians were concentrated in metro-politan areas and general practitioners were prim-cipally found in nommetropolitan areas. Although 27% of the general population lives in nonmetro-politan areas and 28.9% of family physicians have settled in those communities, only 12% of pediatri-ciams have done so. On the other hand, 34% of general practitioners were still located in those areas.

The debate over whether or not increasing phy-sician supply will ameliorate the geographic

maldis-tribution has emerged most clearly following pub-lication of a study by Schwartz et al.8 Using data on five specialties in 23 states for the years 1960, 1970, and 1977, that group concluded that “[t]he percent-age of smaller cities and towns with at least one board-certified specialist of each type has grown, in many cases remarkably, since 1960.” Based upon these findings and supply projections from the Bu-reau of Health Manpower, they predicted that the number of pediatricians “practicing in nonmetro-politan areas will increase more than 55 percent” between 1977 and 1985.

The findings and predictions of this study have been criticized from a variety of viewpoints. The principal indicator used by Schwartz et al-the presence or absence of a single Board-certified spe-cialist-does not help one analyze whether the sup-ply is adequate in some areas and grossly excessive

in others.9”#{176} In particular, because the percent of Board-certified physicians has increased rapidly be-tween earlier years and the 1977 to 1978 period,” the findings of Schwartz et al could simply reflect increasing certification rates, and not an increase in the number of physicians practicing as pediatricians in rural areas. For example, in pediatrics between 1961 and 1976, the percentage of Board-certified pediatricians increased from 48% to 62% of the total.4 Excluding pediatricians who were in training, the results are even more striking; the proportion

of specialists who were Board-certified went from 56.6% to 79.5%, a proportionate increase of 40%. Thus, it is not clear that the trends shown by Schwartz et al are conclusive.

In summary, existing studies demonstrate that pediatricians are more likely than family physicians and general practitioners to be concentrated in ur-ban areas. Approximately two thirds of all counties have no pediatricians; more than half the pediatri-cians are in large communities; and only some 10%

to 15% are in rural areas. This historical pattern is well established, but some analysts now argue that the increasing physician supply will effect a sub-stantial redistribution. In this paper we report new data on physician location that allow us to test this relocation hypothesis. The data are presented and analyzed in terms of metropolitan status of county

of residence, a measure that provides more precise characterization of physician location patterns than was possible in most previous reports. Most

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METHODS

The American Academy of Pediatrics has ob-tamed from the AMA Physician Masterfile the number of pediatricians and the number of family physician/general practitioners (FP/GPs) in each county in the United States. The data are currently available for the years 1976 to 1979. These data are limited to the physicians who are in “direct patient care,” ie, the physicians who are in one of these

three categories: office-based practice;

hospital-based practice with full-time physician staff; and hospital-based practice with residents. In general, residents do not devote as much of their time to patients as do the doctors who are out of residency programs. Thus, it was decided to give the residents a fractional weight of 0.35, the same weight given to them by GMENAC.’2

The data on the number of pediatricians and FP/ GPs were used to calculate the number of “child

health physicians.” The number of child health physicians is defined as the number of pediatricians plus one fourth the number of FP/GPs. Counties

with neither a pediatrician, family physician, or general practitioner were recorded as having no

child health physician. Counties with no pediatri-cian but with one, two, or three FP/GPs were recorded as having .25, .50, and .75 child health physicians, respectively. All other counties had at least one child health physician. This calculation is based on the assumption that family physicians and general practitioners devote approximately one fourth of their practice to children. It should be emphasized that this assumption represents an overall average inasmuch as the actual proportion of a GP’s time spent in child care is subject to much variation. The value of this proportion will depend on a number of factors, including the availability of pediatricians.

In order to assess the adequacy of child health care, it is necessary to compare the number of child

health physicians with the number of children. For the purposes of this analysis, children were defined as the population less than 18 years of age. Esti-mates of the population less than 18 years of age in

each county came from the Survey of Buying Power

published by Market Statistics. By merging these estimates to the AMA physician data, it was possi-ble to calculate the number of children per child

health

physician

in every county of the United

States for the years 1976 to 1979.

The AMA’s “County Group” index was also

merged with the data file. The County Group index comes from the AMA’s Physician Distribution and Medical Licemsure in the United States, 1976. This index measures how “etropolitan” a county is. The index ranges from 1 to 9 with a value of 1

indicating the most rural counties, and a value of 9

indicating the most metropolitan. The values of this

index are defined as follows: (1) nonmetropolitan counties with less than 10,000 inhabitants; (2) non-metropolitan counties with 10,000 to 24,999 inhab-itants; (3) nommetropolitan counties with 25,000 to 49,999 inhabitants; (4) nonmetropolitan counties with more than 50,000 inhabitants; (5) counties considered potential Standard Metropolitan Statis-tical Areas (SMSAs); (6) counties in SMSAs with 50,000 to 499,999 inhabitants; (7) counties in SMSAs with 500,000 to 999,999 inhabitants; (8)

counties in SMSAS with 1,000,000 to 4,999,999 in-habitants; and (9) counties in SMSAs with 5,000,000

or more inhabitants. This index thus allows us to

compare how the distribution of child health care differs between rural and metropolitan areas.

The analysis uses two different standards for the adequacy of the supply of child health care in a given county: (1) whether or not the county has at least one pediatrician for every 2,500 children; and (2) whether or not the county has at least one child

health

physician for every 2,500 children. The

sec-ond

standard, which takes into account the contri-butions of FP/GPs to child health care, is a much more lenient standard than the first.

These standards were selected strictly for pur-poses of comparison. Simple population-to-physi-cian ratios fail to account for many important var-iations in patient needs and practice characteristics, and there is no clear consensus as to the “ideal” number of children per physician.7 Published stud-ies report figures from 1,000 to 4,000 children per child health physician, depending on the method used to calculate physician requirements.’’7 Nev-ertheless, although one cannot generalize from such figures without caution,7 the finding that group practices or health maintenance organizations

(HMOs) often report staffing patterns that result in approximately 1,500 to 2,000 children per child health physician,’4”7 yields a useful reference point. Thus, for purposes of the analysis, it seems reason-able to adopt a standard of 2,500 as an upper limit on the number of children to be served by each

physician. That figure has also been used for illus-trative purposes by the AAP.5

Using these standards, it was possible to estimate

the

“recommended” supply of child health care in each county. By the first standard, if a county had between 1 and 2,500 children less than 18 years of age, the recommended number of pediatricians was

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health physicians according to the second standard was done in a comparable way. However, for the second standard, the number of child health phy-sicians was added in increments of .25, due to the fact that FP/GPs were given a weight of one fourth. In other words, if a county had between 1 and 625 children, the recommended number of child health physicians was .25; if a county had between 626 and 1,250 children, the recommended number of child health physicians was .50; and so on. Using this standard, the recommended number of child health physicians in 1979 was 25,393 “full-time equiva-lents,” representing whatever combination of pedia-tricians and FP/GPs would add up to that total. Using the recommended numbers of pediatricians and child health physicians, it was possible to cal-culate the deficits and surpluses of child health care in each county.

FINDINGS

Distribution

The distribution of pediatricians in the United States is heavily urban and is not proportional to the distribution of children. The distribution of pediatricians is more concentrated in metropolitan areas than the distribution of children. In 1979, more than 87% of pediatricians were in county groups 6 through 9 (Table 1). In contrast, only 72.1% of children lived in these counties. Very few pediatricians are found in the smallest, most rural counties, those in groups 1 to 3 (Table 2). Only

about 1,043 pediatricians (approximately 5.2%) are located in those rural areas, although nearly 11 million children, some 17.5% of the total child pop-ulation, live in these counties (Table 3). Thus, it is clear that the distribution of pediatricians does not closely follow the distribution of children.

Family physicians and general practitioners, however, are distributed much more in proportion

to the location of children. In certain respects, the

distribution follows the reverse pattern of that for pediatricians (Table 1). Relatively few FP/GPs are found in the most metropolitan counties in compar-ison to the distribution of children. In county groups 1 through 5, the groups consisting of the smallest and most rural counties, the proportion of FP/GPs is either close to or even slightly exceeds the

pro-portion of children.

Combining the distributions of pediatricians and FP/GPs results in the distribution of child health physicians, which is a somewhat attenuated version

of the pediatric pattern (Table 1). Because the relative weight of pediatricians in child health is much greater than that of FP/GPs, the more rural distribution of FP/GPs does not fully balance the more urban distribution of pediatricians. The net result is that, as was the case of pediatricians, there are too few child health physicians in rural and small areas and too many in urban areas. Overall, although 87.3% of pediatricians are located in met-ropolitan areas, only 80% of child health physicians and 68.8% of FP/GPs, as compared with 72.1% of children, are located in metropolitan areas.

For children, the implications of the skewed dis-tribution of child health physicians are not as severe as the above percentages might suggest, provided that FP/GPs play a major role. Although a signif-icant proportion of children live in counties with no pediatrician, almost all are located in counties with either a pediatrician, a family physician, or a general practitioner. A fairly large number of children-7,425,098 (1 1.9%)-live in counties with no pedia-trician. However, when FP/GPs are considered, there are only 260,745, or 0.4% of all children who live in counties with no child health physician.

Although almost all children have a child health physician in their county, the majority of the coun-ties do not have an adequate number of child health physicians. More than 63% of the counties in the United States have more than 2,500 children per

child health physician. More than 33% of the

chil-TABLE 1. Percent of Children and Physicians in Direct Patient Care in Counties of

Various Sizes and Metropolitan Status, United States, 1979* County

Group

Children <18 yr Pediatricians Child Health Physicianst

Family Physician! General

Practitioners

1 2.2 (2.2) 0.2 (0.2) 1.2 (1.2) 2.8 (2.8) 2 7.2 (9.4) 1.3 (1.5) 4.3 (5.5) 8.9 (11.7) 3 8.1 (17.5) 3.7 (5.2) 5.9 (11.4) 9.3 (21.0) 4 8.4 (25.9) 5.7 (10.9) 6.8 (18.2) 8.4 (29.4)

5 2.0 (27.9) 1.8 (12.7) 1.8 (20.0) 1.9 (31.3) 6 19.6 (47.5) 17.4 (30.1) 18.3 (38.3) 19.6 (50.9)

7 12.3 (59.8) 13.8 (43.9) 12.6 (50.9) 10.8 (61.7)

8 30.4 (90.2) 39.3 (83.2) 34.8 (85.7) 27.9 (89.6) 9 9.8 (100.0) 16.8 (100.0) 14.3 (100.0) 10.5 (100.0)

* Cumulative values are shown in parentheses.

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TABLE 2. Patient Care Pediatricians, Family County Group, 1979, and Changes 1976 to 1979

Physicians/General Practitioners, and Child Health Physicians by

County Pediatricians Family Physicians/General Child Health Physicians

Group Practitioners

Number Increase 1976-1979

(1979)

n %

Number’ Increase 1976-1979

(1979)

n %

Number* Increase 1976-1979

(1979)

n

1 47.05 18.05 62.2 1,463.05 36.35 2.5 412.81 27.14 7.0

2 254.50 58.40 29.8 4,634.50 123.90 2.7 1,413.12 89.37 6.8 3 741.55 149.40 25.2 4,830.00 134.15 2.9 1,949.05 182.94 10.4 4 1,138.20 180.25 18.8 4,368.50 130.15 3.1 2,230.32 212.78 10.5

5 354.50 62.70 21.5 986.45 80.95 8.9 601.11 82.94 16.0

6 3,484.70 625.60 21.9 10,211.30 775.05 8.2 6,037.52 819.36 15.7

7 2,760.20 486.00 21.4 5,607.65 139.10 2.5 4,162.11 520.77 14.3

8 7,869.95 1,230.60 18.5 14,538.15 411.85 2.9 11,500.49 1,333.57 13.1 9 3,355.00 490.15 17.1 5,471.75 (387.00)t (6.6)t 4,722.94 393.40 9.1

US total 20,001.65 3,301.15 19.8 52,111.35 1,444.5 2.9 33,029.49 3,662.28 12.5

* Fractional numbers are due to weighting residents in training = (0.35) full-time practitioner.

t

Decrease.

TABLE 3.

and Chang

Children and C es 1976 to 1979

hild Per Ph ysician Ratios in Counties by County Group, 1979,

County Children <18 yr % De- No. of Children Aged <18 yr per Physician in Direct Group (1979) crease

1976-1979

Patient Care

Pediatricians Child Health Physicians

Ratio (1979) % Decrease Ratio (1979) #{182}Decrease

1976-1979 1976-1979

1 1,346,257 3.0 28,613 40.2 3,261 9.4

2 4,506,217 3.1 17,706 25.3 3,189 9.2

3 5,073,647 1.9 6,842 21.7 2,603 11.1

4 5,254,907 1.5 4,617 17.1 2,356 10.9

5 1,255,456 3.0 3,541 20.2 2,089 16.4

6 12,265,927 2.4 3,520 19.9 2,032 15.6

7 7,689,347 4.8 2,786 21.6 1,847 16.8

8 18,968,038 4.6 2,411 19.5 1,649 15.6

9 6,137,529 6.5 1,829 20.2 1,300 14.3

US total 62,497,325 3.7 3,125 19.6 1,892 14.4

dren in the United States live in such counties, and they are almost equally divided between

metropol-itan (groups 6 to 9) and nonmetropolitan (groups 1 to 5) areas (Table 4). The situation is, of course, even more severe when one considers the counties in which the ratio of children to pediatrician is greater than 2,500/1. In 1979, nearly 93% of the counties in the United States, containing more than two thirds of the children, failed to meet this stand-ard. Approximately 60% of these children live in metropolitan areas (Table 5).

As noted above, the relatively favorable

distri-bution of child health physicians is dependent on a heavy contribution of FP/GPs to child health care. The role of pediatricians varies across the county groups because of their skewed urban distribution.

In the most metropolitan counties (groups 7 to 9), pediatricians made up the vast majority of child health physicians, between 66.3% and 71.0%. On the other extreme, in the most rural areas (groups 1 to

3), pediatricians represent well less than half of the child health physicians, ranging from 11.4% to 38.0%. In the middle range counties (groups 4 to 6) slightly more than half of child health physicians-51.0% to 59.0%-are pediatricians.

As can be seen from Table 4, there are counties in each of the nine county groups that have fewer than the recommended number of child health phy-sicians. This is true even of the most metropolitan county groups which, on average, have far more than the recommended number. This indicates that the distribution of child health physicians within

county groups is very uneven. The maldistribution

of child health physicians within county groups can be illustrated best by examining several cases in

point. County group 8, the next to the most

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How-TABLE 4. Counties with Less Than One Child Health Physician in Direc per 2,500 Children, 1979

t Patient Care

County No. of % (Cumulative) Children Aged % (Cumulative) No. of

Addi-Group Counties <18 yr in Counties tional Child Health

Physicians

Needed to

Eliminate I)eficit

1 560 28.5 978,563 4.7 278

2 664 33.8 (62.3) 3,351,542 15.9 (20.6) 647

3 270 13.8 (76.1) 2,876,599 13.7 (34.3) 399

4 107 5.5 (81.6) 2,621,121 12.5 (46.8) 296

5 23 1.2 (82.8) 522,570 2.5 (49.3) 41

6 175 8.9 (91.7) 4,369,319 20.8 (70.1) 468

7 69 3.5 (95.2) 1,905,950 9.1 (79.2) 211

8 92 4.7 (99.9) 4,237,082 20.2 (99.4) 491

9 2 0.1 (100.0) 152,948 0.7 (100.1) 13

1,962* 21,015,694t 2,844

* 1,962 of 3,079 counties (63.7%) in United States.

t

21,015,694 of 62,497,325 children (33.6%) in United States.

TABLE 5. Counties with Less Than One Pediatrician per 2,500 Children, 1979

County No. of (Cumulative) Children Aged % (Cumulative) No. of

Addi-Group Counties <18 yr in Counties tional

Pediatricians Needed to

Eliminate Deficit

1 743 26.0 1,291,610 3.1 854

2 883 30.9 (56.9) 4,386,272 10.5 (13.6) 2,011

3 460 16.1 (73.0) 4,833,868 11.5 (25.1) 1,548

4 213 7.4 (80.4) 4,953,352 11.8 (36.9) 1,129

5 44 1.5 (81.9) 1,085,102 2.6 (39.5) 208

6 283 9.9 (91.8) 9,815,590 23.4 (62.9) 1,899

7 103 3.6 (95.4) 4,926,768 11.7 (74.6) 694

8 126 4.4 (99.8) 10,250,388 24.4 (99.0) 1,556

9 5 0.2 (100.0) 398,388 0.9 (99.9) 49

2,860* 41,941,935t 9,948

* 2,860 of 3,079 counties (92.9%) in United States.

t

41,941,935 of 62,497,325 children (67.1%) in United States.

ever, there are important exceptions to this gener-alization (Table 6). In Wayne County, MI, which contains the city of Detroit, there are 24 child health physicians less than that recommended by this standard. In St Louis County, MO, which is part of the suburban region of the St Louis metro-politan area, there is a deficit of more than 50 child health physicians from the recommended number. These deficits are, of course, counterbalanced in the average national figures by other counties in this group such as Dade County, FL, and Los Angeles,

CA, which appear to have large surpluses in the number of child health physicians.

The unevenness of the distributions of pediatri-cians and child health physicians has important implications for calculating the number of addi-tional physicians needed to provide adequate child health care in every county of the United States. For instance, in 1979, there were 20,002

pediatri-cians in the United States. If the distribution of pediatricians were ideal, ie, if no county had pedia-tricians in excess of the number recommended, a total of 26,523 pediatricians would be required for there to be at least one pediatrician for every 2,500 children. Assuming an ideal distribution of pedia-tricians, the total supply of pediatricians falls about 6,521 short of the recommended number. However, as stated above, the distribution of pediatricians is far from ideal. Only 219 counties (7.1%) have the

recommended number of pediatricians. Many of

these counties exceed the recommended standard by large margins. In total, these 219 counties have a surplus of 3,427 pediatricians. It follows that the remaining counties have a total deficit of 9,948 pediatricians.

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County (SMSA)* Children Aged

<18 yr

No. of Children Aged <18 yr

per

Pediatri-cian

Surplus/Deficit

in No. of

Pediatricians 2,115 2,179 3,004 3,980 2,073 2,406 2,398 3,208 1,959 1,521 2,952 3,047 1,930 1,394 1,896 2,612 1,984 1,791 3,158 1,908 2,058 2,018 2,805 5,860 1,381 2,641 679

No. of Children Surplus/Deficit

Aged <18 yr in No. of Child per Child Health

Health Physicians

;‘hysician

_______

1,326 +659 1,470 +407 1,963 +80 2,743 -24 1,572 +145 1,495 +152 1,454 +144 2,255 +19 1,441 +129 1,161 +200 2,130 +30 1,744 +70 1,469 +123 1,109 +190 1,471 +101 1,661 +73 1,431 +107 949 +225 2,059 +27 1,475 +88 1,229 +125 1,626 +65 1,971 +31 4,562 -50 1,028 +156 1,695 +48 548 +363 +135 +86 -50 -101 +50 +8 +8 -39 +48 +111 -26 -30 +47 +120 +45 -6 +37 +54 -27 +39 +25 +28 -13 -65 +87 -6 +274

TABLE 6. Surplus/Deficit in Number of Child Health Physicians for Counties with More Than 250,000 Children

L Angeles Co, CA (Los Angeles) 1,860,510

Cook Co, IL (Chicago) 1,454,598

Harris Co, TX (Houston) 735,342

Wayne Co, MI (Detroit) 675,601

Kings Co, NY (New York City) 613,413 Orange Co, CA (Anaheim) 565,749 San Diego, CA (San Diego) 500,437

Dallas Co, TX (Dallas) 444,492

Philadelphia Co, PA (Philadelphia) 437,343 Queens Co, NY (New York City) 433,099 Suffolk Co, N.Y. (Nassau) 427,232 Maricopa Co, AZ (Phoenix) 406,166 Cuyahoga Co, OH (Cleveland) 402,734 Nassau Co, NY (Nassau) 379,492 Middlesex Co, MA (Boston) 360,976

Allegheny Co, PA (Pittsburgh) 359,920 Santa Clara Co, CA (San Jose) 358,653 Dade Co, FL (Miami) 344,341

Bexar Co, TX (San Antonio) 319,281 Bronx Co, NY (New York City) 318,234 King Co, WA (Seattle) 302,837 Oakland Co, MI (Detroit) 301,621 Erie Co, NY (Buffalo) 290,708

St Louis Co, MO (St Louis) 278,351

Alameda Co, CA (San Francisco) 272,699 Milwaukee Co, WI (Milwaukee) 255,484 New York Co, NY (New York City) 254,678 * SMSA, Standard Metropolitan Statistical Area.

an even distribution of child health physicians, a

total of 25,393 child health physicians were required in 1979 for there to be at least one child health physician for every 2,500 children. In 1979, there were 33,029 child health physicians, which exceeds the recommended number by 7,636. Although the

nation’s supply greatly exceeded the recommended number, only 37% of the counties had enough child

health physicians according to this standard. These counties had a surplus of 10,480 child health phy-sicians whereas the remaining counties had a deficit

of 2,844 from the recommended number.

Trends

Supply. The total number of physicians is

in-creasing very rapidly. Between 1976 and 1979, the number of pediatricians increased by 19.8% for the

nation as a whole. This is a very rapid increase for

such a short period of time. If this rate of growth

were to continue geometrically, the number of pe-diatricians would double every 12 years. As noted above, the average annual increment was approxi-mately 1,100 pediatricians.

Family physicians and general practitioners, on the other hand, increased by only 2.9% for the same

three-year period. On average, FP/GPs grew by 481

per year. If FP/GPs do, in fact, spend approxi-mately one fourth of their time in child health care, as assumed for our calculations, this means that the marginal contribution of FP/GPs is small-about

120 annually-compared with the increment in pe-diatricians. Thus, only about 10% of the net increase

in the number of child health physicians was due to

FP/GPs.

Because the rate of growth for pediatrics has exceeded that for family physicians and general practitioners, the pediatric share of child health has increased. This relative advantage for pediatrics, however, is largely due to the fact that the number

of family physicians only recently began to increase at rates fast enough to offset the decline in the number of general practitioners due to death and retirement.7

The number of family physicians alone is increas-ing by about 2,600 per year. The number of Board-certified family physicians grew rapidly in the early 1970s, then leveled off at 2,623 in 1979 and 1980.”

The number of family practice residency positions

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proportion to the number of retiring GPs, the net annual increase for FPs and GPs combined will rise. For example, GMENAC has estimated that the average net increase for FP/GPs between 1978 and 1990 would be approximately 858 annually,’2 about twice the rate seen for the 1976 to 1979 period.

Distribution. Perhaps the most important finding

of this analysis is that the net increases in the number of child health physicians and pediatricians have been heavily urban. Of the net increase of 3,301 pediatricians between 1976 and 1979, 85% was in the four largest county groups with only 72% of the children (Tables 1 to 3). More than half (52.1%)

of the net increase located in the two largest county groups, where 56.1% of pediatricians already prac-tice and which experienced a decline of 1 1. 1% in child population during this time period. In con-trast, a net increase of only 226 pediatricians, or 68% of the net increase, went to the most rural county groups (1 to 3) although that is where the largest number of pediatricians are needed. The percent growth rate of “new” pediatricians appears to be highest in the most rural counties, but these high rates of growth are somewhat misleading due to the fact that the absolute number of pediatricians in these county groups was so small at the beginning

of the time period. In fact, there was little change in the relative proportion among the various county groups during the time period. The shift of the distribution of pediatricians to rural areas during the three-year period is practically negligible given the extremely fast rate of growth of the population of pediatricians.

The trends are different for FPs and GPs. During the 1976 to 1979 period, counties in SMSAs with 5 million or more inhabitants (group 9) actually lost nearly 400 FP/GPs (Table 2) even though these counties gained nearly 700 pediatricians. The coun-ties in nonmetropolitan areas (county groups 1 to 5) gained 35% of the net increase of FP/GPs in contrast to 14% of the net increase of pediatricians.

Even though the trends for pediatricians and FP/ GPs follow divergent patterns, the net increases in the population of child health physicians mirror almost exactly the net increases in pediatricians. This is, of course, due to the fact that most of the increase in the number of child health physicians is due to the growing number of pediatricians. As noted above, pediatricians account for 90% of the net increase of child health physicians.

Although the majority of the net increase of the population of pediatricians went to metropolitan areas, approximately one of every 15 rural counties (6.6%) was stifi able to improve its pediatric care capacity. During 1976 to 1979, the number of coun-ties with no pediatrician decreased from 1,857

(60.3% of the total number of counties) to 1,735 (56.3%). The vast majority ofthe counties (113/122) that gained their first pediatrician during this time period were in rural areas. More than 90% of these counties were in county groups 1 to 3. The number

of children in counties with no pediatrician declined from 8,761,100 to 7,425,098 during this period, a decrease of more than 14%. The number of counties without child health physicians actually increased slightly from 185 to 187 between 1976 and 1979, although the number of children in these counties decreased from 267,100 to 260,745, a decrease of 2.4%. However, this decrease can be attributed en-tirely to the overall decline in the child population. The proportion of children living in counties with

no child health physician remained absolutely sta-ble at .4% during the study period.

During the 1976 to 1979 period, the number of counties with a deficit from the recommended num-ber of pediatricians, ie, the number of counties with less than one pediatrician for every 2,500 children, decreased by approximately 3%, from 2,944 to 2,860. Although this decrease in the number of counties with a pediatric “shortage” was slight, the total pediatric deficit in those counties fell by an impres-sive 20%. In 1976, the total deficit for all 2,944 such counties combined was 12,428 pediatricians. In 1979, the total deficit for the 2,860 counties below standard was 9,948, a decrease of 2,480 from the 1976 figure. In other words, 2,480 pediatricians (or 75% of the net increase) located in areas with a deficit.

These gains were largely made in metropolitan areas. Overall, 59 of the 84 counties that came up to the standard of 2,500 children per pediatrician were

metropolitan ones. Similarly, metropolitan areas accounted for 10,845,869 or 94% of the net reduction of 11,533,765 children living in counties with defi-cits. In 1976, rural areas made up 48.5% of the deficit

of 12,428 pediatricians. By 1979, the rural areas accounted for 55.7% of the new, lower deficit of 9,948 (Table 5).

A somewhat different pattern of results is shown for the counties with less than one child health physician for every 2,500 children. During the pe-nod from 1976 to 1979, the number of such counties decreased from 2,198 to 1,962. According to this standard, the deficit in the number of child health physicians in 1976 for all 2,198 counties combined was 3,707. In 1979, the deficit for all 1,962 counties below standard was 2,844, a decrease of 863 from the 1976 value. In other words, 863 child health physicians (or only 24% of the net increase of child

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this standard, were already adequately served. In contrast with the pediatric pattern, 172 or 72.9% of the 236 counties that eliminated their child

health physician deficits were rural ones. Because

those are counties of low population, however, they included only 28% of the affected children. Thus, the majority of the child health physicians needed are still in rural areas (Table 4).

DISCUSSION

Limitations of This Approach

Because the available data only specify physician

location by county, the unit of analysis for this report is the county. In many areas, counties are not the most appropriate unit inasmuch as signif-icant numbers of children obtain care across county lines.2 Moreover, looking only at counties in met-ropolitan areas fails to distinguish between central city and suburban practice locations, which may be quite different. Accordingly, the Committee on Pe-diatric Manpower of the AAP has begun a pilot project to analyze appropriate child health service areas. As a first step, detailed data used in prepa-ration of this report are being provided to chapters in the state of Wisconsin for analysis at the local

level. These findings will be cross-checked against local assessments of the relative shortage or abun-dance of child health physicians as a step toward defining child health service areas.

Another limitation of the analytic method em-ployed is that some pediatric subspecialists are necessarily included in the generalist totals. Only pediatric allergists and cardiologists are listed sep-arately by the AMA. Because those two fields make up only one fourth to one third of all pediatric subspecialists, some 2,000 to 2,500 subspecialists are probably included in the pediatric numbers

pre-sented in this report.7 Those subspecialists are likely to be concentrated in the more urban areas, causing the pediatric ratios for metropolitan and large counties to be overstated to some degree. On the other hand, this overestimate would be partially offset to the degree that those subspecialists are providing primary care.

As noted throughout this report, the trends are different for FPs and GPs. These data are useful in the short term but would become increasingly mis-leading for projections well into the future. That is, as the declining number of general practitioners will represent a diminishing fraction of the combined totals in future years, it would be necessary to focus

on family physicians in order to predict long-term trends.

Another limitation of the AMA Masterfile is that osteopathic physicians are not included. Osteopaths

tend to be predominantly generalist physicians and include a substantial proportion of child health care

in their practices.’2 Thus, this omission could un-derstate the manpower ratios in areas where large numbers of osteopaths practice. Inasmuch as osteo-paths are expected to constitute more than one fourth of the FP/GPs in practice in 1990,12 future analyses should attempt to take their numbers into account.

Because there are no empirical data on the actual

child health share of family physicians and pedia-tricians in communities of different sizes, the figures

on the number of child health physicians may be misleading. The crude estimate that child health constitutes approximately one fourth of the practice pattern of FPs and GPs taken together is based upon national data.6 It may be that in small com-mumties, where the ratio of FP/GPs to pediatri-cians is high, the child health share of FP/GPs rises. Similarly, the reverse may be true in the more urban areas where pediatricians predominate.

Finally, the shortcomings of the standard of 2,500 children per practitioner should be noted. As an estimate of the upper limit on physician productiv-ity, that standard probably provides a reasonable

tool

for identifying shortage areas. It cannot be assumed, however, that all communities with more physicians than necessary to meet the standard are experiencing surpluses. More sensitive indicators of local need may be necessary to understand the implications of the apparently large number of phy-sicians who continue to settle in areas with an adequate supply of child health physicians. In par-ticular, the seemingly aberrant finding that so many child health physicians are appearing in areas above the child health standard may simply reflect adult care needs in those communities that are being met by an influx of family physicians.

Implications for Pediatrics

It is unrealistic to expect that pediatricians will make up significant numbers of child health physi-cians in the most rural areas for the foreseeable future. At the current rates of migration, only a trivial number of pediatricians are settling in coun-ties with small populations. Thus, a strategy to assure that all children will have access to pediatri-cians must take these facts into account. It may be that such a strategy simply cannot be attained given the small population base and the style of practice available in rural counties. In that case, it would be incumbent upon pediatrics to cooperate fully with the development of programs to train family phy-sicians and other practitioners who are settling in the most rural areas.

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however, would still take some time to staff fully the most rural areas. It has been widely hypothe-sized that the rapidly increasing supply of physi-cians ultimately would provide more than enough practitioners for rural areas. In fact, more than one third of the net growth in FP/GPs took place in nonmetropolitan areas; but that amounted to slightly more than 500 general physicians settling in those areas during the 1976 to 1979 period, or only some 42 child health physician equivalents annually. Inasmuch as nonmetropolitan areas still require more than 1,600 child health physicians, even the relatively large proportion of FP/GPs set-tling in those areas will not satisfy the estimated need soon, based on these recent trends.

Similarly, the very low number of pediatricians settling in rural counties illustrates the need to consider absolute, and not percentage-based, rates

of growth. That is, if the rates observed for the 1976

to 1979 period were to continue, the prediction by Schwartz et al8 of a 55% increase in pediatricians in nonmetropolitan counties between 1977 to 1985 would be fulfilled; but that would amount to only some 1,100 additional pediatricians in counties in groups 1 to 4, and in 1979 those counties still re-quired approximately 5,500 pediatricians to elimi-nate their deficits (Table 5).

Although they are not increasing rapidly in rural areas, pediatricians do appear to be selecting urban counties with relative shortages. In 1979, those com-munities needed only some 4,000 pediatricians to eliminate their deficits. If the trends identified above continue, that figure will be met very soon-by 1984. Whether the urban preferences of pedia-tncians might begin to moderate if those deficits disappear cannot be predicted, but will be of great interest over the next few years.

CONCLUSION

County data for the 1976 to 1979 period confirm the impression that pediatricians and family phy-sicians are increasing rapidly in number but are exhibiting markedly different patterns of distribu-tion. Pediatricians are found, and these numbers are continuing to increase, in urban counties, largely but not entirely in areas ofrelative shortage. Family physicians show a much greater trend toward set-tling in nonmetropolitan areas, although their

num-bers will not be adequate there for the foreseeable future. Family physicians and general practitioners will continue to provide the bulk of child health care in rural areas unless pediatric preferences change dramatically in the coming decade.

REFERENCES

1. Burnett RD, Bell LS: Projecting pediatric practice patterns.

Pediatrics 62(suppl):625, 1978

2. US Department of Health and Human Services: Report of

the Graduate Medical Education National Advisory

Corn-mittee to the Secretary, DHHS, Vol III, Geographic

Distri-bution Technical Panel. Washington, DC, DHHS

Publica-tion No. (HRA) 81-653, Government Printing Office, 1981 3. Lawlor AC, Reid JT: Hierarchical patterns in the location of

physician specialists among counties. Inquiry 18:79, 1981

4. Wright FH: Survey of pediatricians certified by the Ameri-can Board of Pediatrics up to 1975. J Pediatr 97:1021, 1980

5. Thompson HC, Bornstein SL, Connelly JP: Demographic

and Socio-economic Fact Book on Child Health Care: A

Survey of Trends in the United States. Evanston, IL, Amer-ican Academy of Pediatrics, 1980

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for Our Children: A National Strategy, Vol IV, Background Papers, Select Panel for the Promotion of Child Health.

Washington, DC, DHHS Publication No. (PHS) 79-55071,

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chang-ing geographic distribution of board-certified physicians. N

Engi J Med 303:1032, 1980

9. Rosenblatt RA: Letter to the editor. N EngI J Med 304:916, 1981

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304:917, 1981

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12. US Department of Health and Human Services: Report of

the Graduate Medical Education National Advisory

Corn-mittee to the Secretary, DHHS, Vol II, Modeling, Research

and Data Technical Panel. Washington, DC, DHHS

Pub-lication No. (HRA) 81-652, Government Printing Office, 1980 13. US Department of Health, Education, and Welfare, Bureau

of Health Manpower: Review of Health Manpower

Popu-lation Requirements Standards. DHEW Publication No. (HRA) 77-22. Hyattsville, MD, 1972

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phy-sicians. JAMA 243:355, 1980

16. Schonfeld KH, Heston JF, Falk IS: Numbers of physicians required for primary medical care. N Engl J Med 286:571, 1972

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requirements. Milbank Mem Fund Q53:299, 1976 18. Graettinger JS: Results of the NRMP for 1981. J Med Educ

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Pediatrics

Peter P. Budetti, Phillip R. Kletke and John P. Connelly

Physicians, and General Practitioners Between 1976 and 1979